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Store-And-Forward Teledermatology Applications C A LIFORNIA HEALTHCARE FOUNDATION Store-and-Forward Teledermatology Applications Prepared for CALIFORNIA HEALT H CARE FOUNDATION by UNIVERSITY OF CALIFORNIA, DAVIS DEPARTMENT OF DERMATOLOGY April W. Armstrong, M.D., director of teledermatology Steven W. Lin, M.D., clinical research fellow Fu-Tong Liu, M.D., Ph.D., professor and chair Christopher Sanders, clinical research analyst CENTER FOR HEALT H AND TE ch NOLOGY Aron D. Farbstein, programmer II, George Z. Wu, technical manager Thomas S. Nesbitt, M.D., M.P.H., director, and executive associate dean, School of Medicine December 2009 About the Authors The authors, all with the University of California, Davis, are: April W. Armstrong, M.D., director of teledermatology program, Department of Dermatology; Steven W. Lin, M.D., clinical research fellow, Department of Dermatology; Christopher Sanders, clinical research analyst, Department of Dermatology; Aron D. Farbstein, programmer II, Center for Health and Technology; George Z. Wu, technical manager, Center for Health and Technology; Fu-Tong Liu, M.D., Ph.D., professor and chair, Department of Dermatology; and Thomas S. Nesbitt, M.D., M.P.H., director, Center for Health and Technology, and executive associate dean, School of Medicine. Acknowledgments The authors acknowledge the valuable input of Drs. John Bocachica, Marc Goldyne, Joseph Kvedar, Karen Edison, Hon Pak, Bernard Cohen, Nayla Idriss, and Noah Craft. They thank the members of the American Telemedicine Association Teledermatology Special Interest Group and the Telemedicine Task Force of the American Academy of Dermatology for their participation in this project. They also express appreciation to the technology teams at AFHCAN, Medweb, TeleDerm Solutions, and Second Opinion for communicating with the research team regarding technical evaluation aspects of the project. About the Foundation The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford. For more information, visit www.chcf.org. ©2009 California HealthCare Foundation Contents 2 I. Executive Summary 3 II. Introduction 4 III. Store-and-Forward Teledermatology 5 IV. Evaluation Criteria 7 V. Comparison of Store-and-Forward Applications Alaska Federal Health Care Network (AFHCAN) Medweb TeleDerm Solutions Second Opinion Evaluation Summary 13 VI. Application of Research Findings 15 VII. Conclusion 16 Endnotes I. Executive Summary TELEDERMATOLOGY IS T H E PRA C TI C E OF This report summarizes the key criteria for dermatology using communication technology. evaluating S&F applications. With input from In the United States, this method of facilitating experts in teledermatology, dermatologists at the dermatologic care has been used primarily to improve University of California, Davis (UCD) identified patient access in medically underserved and remote four major commercially available S&F applications communities.1, 2 in the United States. A multidisciplinary team Store-and-forward (S&F) teledermatology, then determined the key elements by which S&F the most common form of teledermatology, offers teledermatology applications should be appraised. several potential advantages over traditional, in-office UCD dermatologists and information technologists dermatologic care.3,4 It has the ability to lower the then evaluated each S&F application according to cost of dermatologic care, increase patient access, these criteria. Experienced teledermatologists with and facilitate medical education and training.5 – 9 But high case volumes were also interviewed regarding potential users can find it difficult to select an S&F their evaluation of the respective S&F applications. application appropriate to their specific needs Implementing an S&F teledermatology program is a sizeable undertaking for practitioners and health care organizations. Successful program implementation requires clear identification of goals, thorough understanding of an organization’s care delivery and business models, and a well-articulated, strategic implementation plan.10 There are several variables that can affect the selection of a particular S&F teledermatology application: characteristics of the practice, patient volume, the medical record filing system currently in use, and financial considerations. 2 | CALIFORNIA HEALT H CARE FOUNDATION II. Introduction TELEMEDI C INE — T H E USE OF TELE C OMMUNI C ATIONS and information technologies to provide health care remotely — has the potential to improve health care by overcoming time and distance barriers and reducing costs. Given the near-universal use of the Internet, the increasing range of remote communication models, and the pressure to cut the cost of health care, the time may be ripe for telemedicine. Yet there are significant barriers to adopting telemedicine in health care systems of all sizes, including a lack of understanding about how to choose and implement available systems effectively. The California HealthCare Foundation commissioned the Department of Dermatology at the University of California, Davis (UCD) to explore how providers select an S&F teledermatology application and to evaluate the major S&F applications in the United States. A multi-disciplinary team of dermatologists, primary care providers, and information technologists was assembled to determine criteria for evaluating S&F teledermatology applications. Through a collaborative effort, the team identified evaluation criteria and performed an analysis of each application using the evaluation criteria and interviews with expert teledermatologists. Store-and-Forward Teledermatology Applications | 3 III. Store-and-Forward Teledermatology TH ERE ARE T H REE MAJOR MODELS OF readily available than that required for real-time teledermatology delivery: S&F, live interactive, and teledermatology.2 On the other hand, the lack of the hybrid model. Among these models, S&F is the interaction between the dermatologist and the most commonly used; yet each model has advantages patient in the S&F modality is often perceived as and drawbacks.1 Selecting among these modalities a disadvantage. depends on the specific needs, preferences, and objectives of referral and consultant sites. Figure 1. S&F Teledermatology Consult Process The practice of S&F teledermatology entails the capture of still digital images and clinical information (e.g., history of present illness) and transmission of this information from referring providers to Primary care provider 1 sees patient dermatologists for asynchronous review. This with skin conditions. modality is similar to an email system in which users are not required to be simultaneously engaged at 2 their computers. Primary care provider or S&F teledermatology is an innovative, 2teledermatology coordinator takes technology-enabled method of providing specialist digital photographs of skin lesions. care to patients who live in medically underserved or remote areas. Patients may benefit from decreased travel time and costs associated with visiting a History and digital images 3 are securely transmitted dermatologist, as well as to improved access to to a dermatologist. dermatologic care.1 Referring providers in remote areas benefit from S&F teledermatology because they gain access to specialists’ opinions.2 Dermatologist reviews case Generally, an S&F teledermatology consult is 4and provides recommendations to the primary care provider. conducted as shown in Figure 1. S&F teledermatology differs in three major ways from live interactive teledermatology and the hybrid Source: University of California, Davis, Department of Dermatology. model. First, it is asynchronous, which saves the resources required to coordinate mutually agreeable appointments.2 As a result, some teledermatologists contend that S&F teledermatology consultations may be more efficient than real-time consults.2 In addition, the hardware required for S&F consultations is generally less expensive and more 4 | CALIFORNIA HEALT H CARE FOUNDATION IV. Evaluation Criteria IMPLEMENTING A TELEDERMATOLOGY PROGRAM to estimate patient volume, hours necessary for is not easy. Despite the reported potential benefits teledermatology coordinators, reimbursement rates, of teledermatology, many programs have not equipment costs, and specialist compensation before flourished.9 Researchers have cited several reasons implementation. Among these factors, estimating why some programs are successful while others are patient volume and the number of hours necessary not. For example, S&F teledermatology programs for a teledermatology coordinator are the most have been successful in government organizations, challenging. Due to the natural ebb and flow of such as the Department of Defense, and in closed patient volume, hiring a part-time teledermatology health care systems, where the organization has coordinator or sharing the cost of a medical staff reasonable financial incentives to implement S&F member might be appropriate for clinics without teledermatology. In contrast, many other health care constant, high patient volumes. organizations have complex referral and authorization Finally, if the program does not have “buy processes, which may impede implementation of an in” from the organizational leaders and referring S&F program. Therefore, the initial steps in creating physicians, it likely
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